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PUBLIC NOTICE
Louisiana Permanent Supportive Housing
Project‐Based Rental Assistance
Florida Parishes Human Services Authority (FPHSA) Permanent Supportive Housing (PSH) program will
be accepting applications from September 07, 2009 through September 21, 2009.
PSH units are located throughout the Florida Parishes area in Livingston, St. Helena, St. Tammany,
Tangipahoa, and Washington parishes.
Applicants must meet each of the following PSH eligibility requirements:
• The household income must be at or below thirty percent of the area median income;
• The applicant must have a household member with a physical, mental, or emotional impairment
that is expected to be long‐term; and
• Because of the disability, the household must be in need of supportive services in order to live
independently and successfully in the community.
A completed application is considered as having all of the following:
• A completed PSH application form;
• A completed “In‐Need of PSH” verification form completed ONLY by a doctor, case manager,
nurse, or other professional; and
• Documentation of all current income.
If you are in need of assistance completing an application, you may call 985‐748‐2220 to schedule an
appointment.
Persons with hearing disabilities may access relay services through 711.
Completed applications and supporting documentation will only be accepted via mail. Applications will
not be accepted in person. Completed applications should be returned to the address listed on the
application no later than September 21, 2009. Applications postmarked by the U.S. Postal Service after
September 21, 2009 will not be accepted.
Florida Parishes
Human Services Authority
Livingston Parish St. Tammany Parish Tangipahoa Parish
Judge Zoey Waguespack John Tobin Marty Dean Chris Miaoulis
Margie Mason Kathy Hayward Mark Waller, Chairman
Dear Applicant,
What is PSH?
PSH are special rental apartments that come with supports for people who have difficulty living
successfully in the community and may become homeless or institutionalized without supports.
These housing supports include things like reminders to pay the rent and keep your apartment
clean as well as help arrange medical appointments or other support services. Only people with
disabilities including elders, youth and homeless individuals and families who need these types of
supports are eligible for PSH.
PSH Requirements
To be eligible for PSH, your household must (1) have a member who has a disability, (2) need
the housing supports offered by the PSH Program, and (3) have a household income within the
HUD established income limits, preferably extremely low-income.
• First, complete the attached application. While we hope you answer all the questions, we
can begin to process your application as long as you answer all of the questions that have
a asterisk next to them. Eventually you will need to answer all of the questions and
provide documents verifying your answers. You cannot be found eligible for PSH or
offered a unit until we have a complete application and all the supporting documentation.
• Second, Florida Parishes Human Services Authority must verify you are in need of the
supports offered through PSH. Please have your doctor, case manager, or some other
professional complete the attached “In-Need of PSH” Verification form and certify it with
their signature and agency information.
• Finally, send in proof of each household member’s income. Failure to comply could result
in your application not being processed.
It is important that we can get in touch with you. Please provide as many phone numbers as possible.
________–_______–________ ______/______/______
Social Security Number Birth Date
Optional: You may provide an alternative contact in the event that your contact information
changes and we cannot locate you.
Address: _____________________________________________________________________
Street City State Zip Code
Page 1 of 9
Your Race (Voluntary – Please select one or more):
White Black or African American
American Indian/Alaskan Native Asian
Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native and White
Asian and White Black/African American and White
American Indian/Alaskan Native and Black Other
Ethnicity (Voluntary - please select “yes” or “no” for Hispanic Origin. You should select both a
“Race” category and a “yes” or “no” for Hispanic origin): Hispanic: Yes No
Citizenship (please check) Are you a citizen of the United States? Yes No
(Some noncitizens are eligible for this program)
Elder - Defined as a head of household over 62 years of age (please check) Yes No
Aging Out Youth: You are aging out of the state Foster Care system
(please check) Yes No
Accessibility: Does a member of your household require the special design features of a particular
unit (e.g. wheelchair access or access for person who has a hearing disability)
(please check) Yes No
1.) *Does a member of your household have a substantial, long-term disability including
but not limited to serious mental illness, addictive disorder, developmental disability, physical or
sensory disability, chronic illness such as HIV or a frail elder?
Yes No
In order to help you access any needed supports for local or state agency it is helpful for us to
know what type of disability you have. This information is voluntary and confidential and will
NOT impact your eligibility.
*Please estimate the total annual income for everyone who will live in the household: $
There is an income worksheet at the end of this application which you need to complete. If your
income is above these amounts, you may still be eligible for the program.
Page 3 of 9
PREFERENCE POINTS
Depending upon your current housing circumstances, you may qualify for a preference under
this program. Please review the housing situations described on the next two pages and answer
all questions that might describe your personal housing situation. Failure to check off the type of
preference and the details that describe your situation will result in you not receiving those
preferences until verified.
If you answered “yes”, were you able to return to this address? Yes No
If you answered “yes” that this is a temporary living situation, please explain:
If you checked this box and are currently in a homeless shelter, please list the Shelter’s name
and telephone number:
____________________________________ (_____) ____________________
Shelter Name Telephone No.
Page 4 of 9
Are you at Risk of Homelessness or Living in Transitional Housing for
the Homeless? Yes No
Is your household in one of the following situations, don’t have anywhere else to live and not
enough funds to pay for housing? (If yes, check the one that applies to qualify for this preference)
Household is being evicted or foreclosed within 30 days by a private landlord?
Household is being discharged within 30 days from an institution, such as a mental health
or substance abuse treatment facility, in which you lived for more than 30 days?
Household is fleeing a domestic violence housing situation?
Household is living in temporary housing situations such as in motels, hotels, and FEMA
trailers or in an untenable doubled up arrangements?
Household is exiting, mental health or developmental disability facilities, nursing homes,
residential addiction treatment programs, or hospitals?
Household includes youth aging out of foster care who qualify for PSH?
Household is living in transitional housing but did not originally come from emergency
shelter or a place not meant for human habitation
HOUSEHOLD INFORMATION
List all persons who will be living in the unit and their relationship to the Head of Household (HOH).
Complete the information in the chart for all members of the household.
First Last Name Relation to Birth Date Age Sex Social
Name Head Security #
HOH
Does a member of the household require 24-hour care by a caretaker or live-in aide? Yes No
Page 5 of 9
SUMMARY OF HOUSEHOLD INCOME AND ASSET SOURCES
Please put the annual amount of income for each household member in the boxes as appropriate.
Head Member 2 Member 3 Member 4 Member 5 Member 6 Member7
Employment
Child Support
SSI
SSA
Pension Income
Public Assistance
Self Employment
SSDI
Other
Other
TOTAL
ASSETS
1.) Do you own real estate? Yes No
If yes, please provide the address:
Page 6 of 9
List below the assets of everyone to live in the unit; include all bank accounts, stocks and bonds,
trusts, real estate, etc.
DO NOT include clothing, furniture, or cars. Use additional paper if necessary.
Checking Account
Savings Account
Stocks, Bonds
Trust
IRA, Other Pension
Other
EXPENSES
1. Do you pay for child care for a member of the household age 12 or younger that allows
you or another adult to work, look for work, or go to school?
Have you or any member of your household who will live in the unit have a criminal record?
Check one: Yes No
If you checked “yes”, please provide a detailed explanation of the charges and the years these
charges took place:
______________________________________________________________________________
______________________________________________________________________________
Page 7 of 9
PSH UNITS IN FLORIDA PARISHES HUMAN SERVICES AUTHORITY REGION
Florida Parishes Human Services Authority has PSH housing in all of the locations listed below.
Check next to each parish/area indicating your interest in residing at that location. Do NOT
check any locations where you would not consider living.
Check if interested Parish Area
Livingston Parish All
St. Helena Parish All
St. Tammany Parish Covington
St. Tammany Parish Slidell
Tangipahoa Parish Amite
Tangipahoa Parish Hammond
Washington Parish All
COMMUNICATION
Do you have a case worker or other professional that we may contact to discuss the status of your
application (other than your local lead agency’s representative)? If so, please list their name
below. You will be asked to sign a separate consent form allowing us to contact this person.
Name
Agency
Phone or e-mail:
If you are not being referred by an agency or service provider, please provide us with the
following information:
How did you hear about the Louisiana Permanent Supportive Housing Program?
______________________________________________________________________________
______________________________________________________________________________
Name Relationship
______________________________________ ______________________________
______________________________________ ______________________________
______________________________________ ______________________________
Privacy Act Statement: The information on this form is being collected on behalf of the
Department of Housing and Urban Development (HUD) to help determine an applicant’s
eligibility. It will be used to provide the basis for managing the program covered by this form,
for protecting the Government’s financial interest and for verifying the accuracy of the
information furnished.
Penalty for false or fraudulent statements: U.S.C. Title 18, Sec 1001, provides that
“Whoever, in any matter within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a
material fact, or makes any false, fictitious or fraudulent statements or representations, or makes
or uses any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than
five years, or both.”
Applicant(s) Statement: I/we understand that false statements or information are punishable
under federal law.
___________________________________________________________ _______________
*Applicant Signature *Date
Page 9 of 9
Florida Parishes Human Services Authority
“In Need of PSH”
Verification Form
This form must be completed and signed to certify that someone applying for Permanent Supportive Housing has a need
for the tenancy supports provided in the program.
Generally a case manager, services provider, doctor, nurse or other professional who knows you can complete
and sign the form. If you do not have anyone to sign the form, please contact the Permanent Supportive Housing
Department.
Certification of the need for PSH supports is one of the three program eligibility requirements. The other two are (1)
having a disability, and (2) being extremely low‐income.
Applicant’s Name: ______________________ ___________________________________
Yes No Does at least one member of this household have a physical, sensory, mental, emotional or
cognitive disability which is expected to be chronic and/or permanent?
Explanation required: _______________________________________________________________________________________________________
______________________________________________________________________________________ _______________
______________________________________________________________________________________ _______________
______________________________________________________________________________________ _______________
Yes No As a result of this member’s disability, does this household require the types of tenancy supports
provided by the PSH Program in order to live successfully in the community and maintain a stable
tenancy? Some of the types of supports that can be provide by the program may include assistance
developing housing skills such as home maintenance, shopping, cooking, budgeting and bill and
rent payment.
Explanation required: _______________________________________________________________________________________________________
______________________________________________________________________________________ _______________
______________________________________________________________________________________ _______________
______________________________________________________________________________________ _______________
Please describe how you believe the PSH Program supports can assist the applicant household to live
successfully in the community. Please be specific.
Explanation required: ______________________________________________________________________________________ _________
______________________________________________________________________________________ ________
______________________________________________________________________________________ _________________
______________________________________________________________________________________ _________________
I certify that the foregoing information is true and accurate to the best of my knowledge.
Agency Name/ Address _______________________________________________________________________________________________________
Agency Address City, State Zip
Please return this form by mail or fax:
Florida Parishes Human Services Authority . Permanent Supportive Housing . 11236 Hwy 16 . Amite, Louisiana . 70422 . Fax: (985)748‐2236
Application Checklist
Only completed applications will be processed. A completed application is considered as having all of
the following:
To ensure the acceptance and processing of your application, please use the following checklist before
submitting your application:
I have attached documentation of my household’s current income (i.e. award letters, check
stubs, etc.)
I have attached the “In-Need of Supportive Services” form that was completed and certified
ONLY by a case manager, services provider, doctor, nurse or other professional.
Once completed, you may send your application to the following address:
Fax: 985-748-2236